Gynecologic Oncology
Clinical discussions on gynecologic malignancies, surgical approaches, and multimodal treatment strategies.
Recent Discussions
What is your approach to adjuvant treatment for stage IA small cell carcinoma of the ovary, hypercalcemic type, after fertility sparing surgical staging?
Due to the rarity of small cell carcinoma of the ovary hypercalcemic type (SCCOHT), limited prospective data exists to inform treatment decisions. Like other malignancies in the malignant rhabdoid tumor (MRT) family including renal and extra-renal MRT and atypical teratoid rhabdoid tumors (ATRT), SC...
Does the presence of an ATM mutation in advanced stage ovarian cancer influence the decision to use Bev vs PARP inhibitor for maintenance?
I would not use the presence of an ATM mutation alone to inform decisions between bevacizumab vs PARPi maintenance. There are several options for maintenance in the 1L setting, and these include single agent PARPi, PARPi + bevacizumab, or bevacizumab monotherapy. Using data from the PAOLA-1 trial, i...
How would you manage a large grade 2 endometrial adenocarcinoma with invasion into the parametria and upper vagina without nodal or metastatic disease?
PETCT and MRI. Preoperative chemo RT with EBRT plus brachy followed by surgery. Vargo et al., PMID 25218303
Is it necessary to include entire lymphocele in CTV while treating post operative nodal sites of pelvic malignancy?
I don’t know if necessary or not but I tend to include it if can do it safely. If large and pathological node was negative, then skip to reduce dose to OAR.
When a patient with a preexisting rheumatic disease and on immunotherapy begins to flare, how do you decide if this is an underlying rheumatic disease activity versus an immunotherapy related adverse event?
If the symptoms/signs are similar to their prior flares of their rheumatic disease, then it is likely a flare. Over 50% of patients with autoimmune diseases flare on immune checkpoint inhibitor therapy if you look at systematic literature reviews of the limited published data. If symptoms are unrela...
Would you consider definitive radiation therapy (EBRT + interstitial HDR) in lieu of pelvic exenteration for a vaginal spindle cell sarcoma?
I would not favor definitive RT unless not a surgical candidate but sometimes have been able to do EBRT plus brachy after gross total excision to avoid exenteration.
Would you consider adding adjuvant vaginal cuff brachytherapy for a FIGO 1A endometrial cancer, G1, no LVSI, based on the presence of extensive lower uterine segment involvement?
It’s not an absolute indication for adjuvant brachy with small absolute benefit.
How would you proceed when a cervical cancer undergoing brachytherapy has exceeded the rectal dose but not met the target dose?
Rectal dose and target dose have range. Preferred rectal dose for D2cc < 65 Gy but can accept up to D2cc < 75 Gy, provided you understand expected risk of complications with increased dose. Preference would be to do hybrid applicator with 3D imaging to optimize HRCTV and OAR.
How would you manage a dehiscent vaginal cuff 2 months after vaginal cuff brachytherapy?
It has to be a combination of surgery and radiation. Partial small dehiscence can sometimes be managed conservatively otherwise, most need surgical fixation.
How would you treat a recurrent ovarian malignant mixed Mullerian tumor on the pelvic side wall?
I would treat with IMRT and IGRT with total dose equivalent to 66 Gy based on OAR dosimetry to buy time without chemo and improve PFS.